Insurance law tied to more breast reconstruction

NEW YORK (Reuters Health) - Many more breast cancer patients had breast reconstruction following a 1998 federal law mandating insurance coverage for the procedure, according to a new study.

"I think it's the first large-scale study that shows that, slowly, legislation like the Women's Health and Cancer Rights Act is having an effect," said Dr. Evan Garfein, a plastic surgeon who has helped to draft a New York law aimed at improving access to breast reconstruction but who was not involved in the new research.

The study's authors note that the greatest increases in reconstructions were among women on Medicaid and Medicare, suggesting that before the law, the uninsured cost of the procedure was an obstacle for many poor breast cancer patients.

But researchers cautioned against interpreting the study results to give all the credit to the legislation.

"The utilization of reconstruction overall has increased over the study time period because surgical techniques have changed and we've also expanded the people that are eligible for reconstruction compared to what was possible even 10 years ago," said Dr. Rachel Kelz, an assistant professor of surgery at the University of Pennsylvania in Philadelphia and one of the authors of the study.

Breast reconstruction is considered by many to be part of the recovery from breast cancer.

Mastectomy (surgical removal of the breast) "can be a fairly deforming operation," said Garfein, of New York's Montefiore Medical Center. "Reconstruction is helpful in restoring a sense of self, it's helpful in restoring a sense of sexuality, it's helpful in helping women move on from treatment of the disease."

In an effort to make sure all women have access to the procedure, Congress passed the Women's Health and Cancer Rights Act of 1998.

The law requires health insurance plans that cover mastectomy to also cover plastic surgery to reconstruct the breast.

Past research has shown that not all women are equally likely to get reconstruction; women with private insurance are more likely to have the surgery than women with Medicare and Medicaid, Garfein said.

To see whether those tendencies have been changing, Kelz and her colleagues gathered information from a large database of hospital patients' records.

Between the years 2000 and 2009, more than 168,000 women in the database underwent breast removal and 35,000 of them had breast reconstruction immediately following the cancer treatment.

As a percentage of all the women treated for breast cancer in a given year, the number who got reconstructions rose from roughly 13 percent in 2000 to 36 percent in 2009, the team reports in the medical journal Cancer.

The greatest increase in reconstruction rates over this decade was among women covered by Medicaid, the government-funded health insurance for the poor.

In 2000, just about five percent of the women on Medicaid had the surgery, whereas 20 percent had it in 2009, a four-fold rise.

Similarly, reconstruction rates among women on Medicare, the government-funded insurance for seniors or the disabled, nearly tripled, from 4.3 percent to 12.3 percent.

Women with private insurance more than doubled their rate of reconstructions, from 22.1 percent to 57.1 percent.

Kelz said the increases are likely due in part to the Women's Health and Cancer Rights Act.

"Some of this has nothing to do with policy changes, but you would expect the same rates of expansion to affect different groups equally if it was just related to technical expertise," she told Reuters Health.

Garfein said the overall increases in reconstruction were "quite a jump," but that there is still a long way to go in leveling the disparities in who gets the procedure.

Rachel Yang, the study's lead author and a medical student at the University of Pennsylvania, said one of the reasons women without private insurance don't get breast reconstruction as often could be because their doctors aren't referring them for the procedure.

And that could be because doctors at facilities that treat patients with Medicaid don't have the time to discuss reconstruction options.

Yang said it's important that all physicians discuss the options with their patients.

Garfein said it's also possible that doctors might not be referring patients for reconstruction because there isn't a readily available plastic surgeon to do the procedure.

"It is really incumbent upon all hospitals, anyone that treats breast cancer, to make sure that reconstruction availability is not only a theoretical option but an actual option," he said.

Patient education is also an important component of making sure women can choose the best option for breast cancer treatment, said Yang.

Not all women are going to want reconstruction, she said, "but we believe that all women should have access to it and all women that want it should have the conversation with their provider about this option."